A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?
Observe for signs of infection
Examine the skin for generalized urticaria
Review laboratory test results for low hemoglobin
Monitor the mouth for signs of xerostomia
The Correct Answer is A
Radiation therapy can cause immunosuppression, which increases the risk of infection. The nurse should monitor the client for signs of infection such as fever, chills, malaise, or purulent drainage.
- Examine the skin for generalized urticaria. This is not a common side effect of radiation therapy, as urticaria is an allergic reaction that causes hives or welts on the skin. Radiation therapy can cause localized skin irritation, erythema, or dryness, but not generalized urticaria.
- Review laboratory test results for low hemoglobin. This is not a direct effect of radiation therapy, as hemoglobin is a component of red blood cells that carries oxygen in the blood. Radiation therapy can cause anemia, which is a low number of red blood cells, but not necessarily low hemoglobin.
- Monitor the mouth for signs of xerostomia. This is not relevant for a client who receives radiation therapy to treat lung cancer, as xerostomia is dry mouth caused by reduced salivary gland function. This can occur in clients who receive radiation therapy to treat head and neck cancer, but not lung cancer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Repositioning the client is the appropriate action for the nurse to take, as chest burning may indicate that the chest tube is kinked, twisted, or compressed, which can impair drainage and ventilation. The nurse should gently move the client to a different position and check that the chest tube is not bent or occluded by clothing, bedding, or furniture. The nurse should also ensure that there are no dependent loops or coils in the tubing and that it is secured to prevent dislodgment.
a) Increasing the client's wall suction is not advisable, as it can cause increased negative pressure in the pleural space and lead to tension pneumothorax. Increasing the wall suction does not affect the patency of the chest tube or the drainage of air or fluid from the lung. The nurse should maintain the wall suction at the prescribed level and monitor for any changes in the suction chamber.
c) Clamping the client's chest tube is not advisable, as it can cause air or fluid accumulation in the pleural space and lead to tension pneumothorax. Clamping the chest tube does not relieve chest burning or improve drainage or ventilation. The nurse should only clamp the chest tube for a brief period of time and under specific circumstances, such as changing the drainage system, assessing for an air leak, or preparing for chest tube removal.
d) Stripping the client's chest tube is not advisable, as it can cause increased negative pressure in the pleural space and lead to tissue damage or bleeding. Stripping the chest tube involves applying manual pressure along the tubing to force out any clots or debris that may obstruct drainage. However, this practice is not recommended, as it can cause more harm than good. The nurse should only milk the chest tube gently and intermittently if ordered by the provider and if there is evidence of obstruction.
Correct Answer is ["B","C","E"]
Explanation
These actions help to control bleeding, reduce blood pressure, and promote clotting.
a. Tilt the client's head backward. This is not recommended, as it can cause blood to drain into the throat and increase the risk of aspiration, nausea, or vomiting.
d. Instruct the client to blow his nose. This is not advisable, as it can dislodge any clots that have formed and worsen bleeding.
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